Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Powder River Manor during CMS and state inspections, most recent first.
Food items were found opened and undated on kitchen shelving, including oils, spices, oats, cereal, and instant potatoes. The kitchen manager stated staff were responsible for dating opened items and acknowledged that staff did not date food items when they were opened.
The facility failed to protect residents from abuse when one resident without capacity to consent was found in a common area with another resident’s hand inside her brief, and the subsequent investigation did not include interviewing or assessing other residents who might have been affected. In a separate event, a resident shook his spouse’s head and later sprayed water in her face with a spray bottle when she was tired at dinner, causing her agitation, while both continued to share a room and she spent most of her time and slept in common areas due to ongoing behaviors between them, as reflected in her care plan.
Inaccurate MDS Assessments for Diagnosis and ROM: Two residents had MDS entries that did not match their observed or documented status. One resident’s MDS listed active pneumonia despite no current respiratory symptoms, no oxygen use, and no recent treatment or provider notes, while another resident’s MDS showed no limited ROM even though the resident could not lift the left arm above the shoulder. Staff said diagnoses auto-populated from the EHR and that a remote nurse completed the assessments.
A resident with dementia and memory problems had a documented history of trying to go outside alone and checking bird feeders, with a wander guard placed on the walker to alert staff. However, direct care staff interviewed did not recognize the resident as a wander risk, and one staff member stated the resident went outside when the weather was nice with activities staff, while another could not explain why the care plan did not reflect those outings or why staff were unaware of the risk.
Survey results completed by the State Survey Agency were not available in the designated, publicly accessible area. Observations found the labeled file holder empty on multiple occasions, and staff interviews revealed unawareness of the binder's location or absence.
A resident's POLST form was found incomplete, missing both the responsible party's and provider's signatures, as well as the date and provider's printed name. The form, which indicated No CPR and selective treatment, was not valid according to facility policy and state requirements, and staff could not explain why it was not properly completed.
A resident sustained a partial thickness facial burn after a CNA, without proper authorization or supervision, applied a hydrocollator heat pack to the resident's face for dental pain and left it on for 30-40 minutes without monitoring. Staff interviews revealed inconsistent training and understanding of heat pack use, and documentation failed to show appropriate assessment or monitoring before, during, or after the application.
A resident sustained a second-degree facial burn from a heat pack, resulting in pain, redness, swelling, and blistering. Staff observations and medical records documented the severity of the injury and the need for treatment, but the facility's reports to the State Survey Agency understated the extent of the injury and omitted key details, failing to provide accurate documentation of the event and investigative findings.
The facility failed to report and investigate allegations of neglect involving two residents. One resident was left unattended in a room without a call light, while another was found in a heavily saturated brief with a dried bowel movement. Staff members reported these incidents, but no action was taken due to a personal friendship between the involved staff members. The facility's policy requires such allegations to be reported and investigated, but this was not done, resulting in a deficiency.
Food Items Left Undated After Opening
Penalty
Summary
Food items were not labeled and dated after opening, and the facility failed to store, prepare, distribute, and serve food in accordance with professional standards. During an observation and interview on 4/21/26 at 7:40 a.m., surveyors found multiple opened items on open shelving to the right of the grill and stovetop that were not marked with the date they were opened, including a large plastic bottle of cooking oil, a large plastic bottle of butter-flavored oil, a large container of parsley flakes, a large container of dry chopped onions, a round container of Quaker oats, a box of Malt-O-Meal hot breakfast cereal, a box of instant mashed potatoes, a large container of ground ginger, a large container of ground coriander, and a large container of whole sesame seeds. The kitchen manager stated she had been in that role for 12 years, tried to get staff to date items when opened, and was aware that staff did not date food items when they were opened. On 4/22/26 at 2:00 p.m., she stated she did not have much storage space and felt items were used quickly enough to be safe, and that all staff were responsible for dating food items.
Failure to Protect Residents From Sexual and Physical Abuse by Other Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse, including sexual and physical abuse, by other residents. In one incident, a resident without capacity to consent was found in a common area with another resident’s hand inside her brief up to the wrist. Staff immediately separated the residents, and the incident was reported to the State Survey Agency; however, the facility’s investigation did not include interviewing or assessing other residents who might have been present or potentially affected by similar sexual abuse incidents. A staff member also reported that the incident was initially reported under the wrong license type because they were unaware the facility held both an adult day care and a skilled nursing facility license. In a separate incident, a resident became upset with his spouse, also a resident, during dinner and shook her head to wake her, then later sprayed water in her face with a spray bottle after staff had intervened and moved her to the nurses’ station. The spouse became agitated by these actions. Observations showed that the couple continued to share a room, with both residents’ nameplates and belongings present. Staff interviews indicated that the spouse who was the target of the behavior was usually kept out of the room and spent most of her time and slept in common areas or by the nurses’ station due to ongoing behaviors between the two. The care plan for the spouse reflected that she was not to be in the room when her husband was present unless both wanted to be there, and staff were to intervene if yelling occurred, based on the prior incident of head shaking and use of the spray bottle.
Inaccurate MDS Assessments for Diagnosis and Range of Motion
Penalty
Summary
The facility failed to ensure the accuracy of MDS assessments for 2 of 12 sampled residents. For one resident, a Quarterly MDS with an ARD of 2/27/26 listed an active diagnosis of pneumonia even though observation showed the resident seated in the dining room eating lunch without shortness of breath, cough, or other respiratory symptoms and not using oxygen. Review of the EHR showed no treatment, medication, or provider notes related to pneumonia during the past six months, and the diagnosis list showed pneumonia as a history from 2022. Staff stated the MDS system auto-populated diagnoses from the EHR and that the nurse completing the MDS remotely should have manually corrected the diagnosis list to show no current pneumonia diagnosis. For another resident, observation and interview showed limited movement of the left arm, as the resident was unable to lift the left arm above the shoulder. However, the admission MDS with an ARD of 3/17/26 indicated no limited range of motion. Staff stated the nurse who had been completing MDS assessments had left the facility, and a nurse was hired remotely to complete assessments while staff were in MDS training. Staff could not explain why the remote nurse documented the range of motion information incorrectly, and noted that prior assessments from 2022 also showed no limited range of motion.
Wandering Risk Not Communicated to Staff
Penalty
Summary
The facility failed to ensure direct care staff were aware of a resident's wandering behaviors and the need for increased monitoring when the weather warmed up for 1 of 12 sampled residents. Resident #6 had dementia with memory problems, and the care plan initiated on 4/7/21 documented that the resident sometimes attempted to go outside on her own repeatedly, so a wander guard bracelet was placed on her walker to alert staff. The same care plan also noted a history of the resident going outside alone to try to check the bird feeders. During an observation on 4/22/26, resident #6 was seated in the dining room eating breakfast and later used her wheeled walker to ambulate back to her room. In interviews that day, staff member F stated the resident was not a wander risk and did not have a wander guard on her person or walker, and staff member E also stated the resident was not a wanderer and did not try to leave the facility. Staff member B stated the resident went outside when the weather was nice and that activities staff accompanied her outside to fill the bird feeders, but could not explain why the care plan did not include these warm weather outings or why some staff were unaware of the resident's wander risk. The facility policy on elopements and wandering residents stated that interventions to increase staff awareness of the resident's risk and minimize hazards would be added to the care plan and communicated to appropriate staff.
Survey Results Not Publicly Accessible
Penalty
Summary
The facility failed to ensure that the results of surveys completed by the State Survey Agency were readily available and located in a publicly accessible area. During observations on two separate occasions, the wall-mounted file holder labeled 'SURVEY RESULTS' at the facility's entrance did not contain any binder or documents for viewing. Staff interviews confirmed that the binder with survey results was not present in the designated holder, and staff were unaware of its location or why it had not been returned. This lack of accessible survey results would affect any person wishing to view them.
Incomplete POLST Form Lacking Required Signatures and Provider Information
Penalty
Summary
The facility failed to ensure that a completed Physician Orders for Life-Sustaining Treatment (POLST) form was readily accessible and properly executed for one of five sampled residents. During record review, it was found that the resident's POLST form indicated selections for No CPR and selective treatment, and was filled out by the resident's responsible party. However, the form was missing the responsible party's signature, the provider's signature, the date, and the printed name of the provider. This incomplete documentation meant the POLST was not valid according to facility policy and state requirements. During an interview, a staff member stated that admission forms, including POLST forms, are typically reviewed by staff, the resident, or the responsible party, and sometimes provided to the responsible party to complete before admission. The staff member was unable to explain why the POLST for this resident was not fully completed with all required signatures and information. Facility policy and provided guidance clearly require both the provider's and the legal decision-maker's signatures for the POLST to be valid.
Resident Burn Injury Due to Improper Heat Pack Application and Inadequate Staff Supervision
Penalty
Summary
Nursing and nurse aide staff failed to perform care within their scope of practice, did not provide sufficient supervision, and did not conduct adequate pain assessment or monitoring during the application of a heat pack for one resident. A certified nursing assistant (CNA) obtained a hydrocollator heat pack from the physical therapy department without permission and applied it to a resident's face for dental pain. The CNA left the heat pack on for 30-40 minutes without monitoring, resulting in redness and subsequent blistering on the resident's face. The CNA reported the redness to a nurse but did not recognize the severity of the injury until the following day, when blistering was observed and reported to the nurse on duty. Interviews revealed inconsistent staff understanding and training regarding the use of heat packs, with some staff stating that only therapy or charge nurses were permitted to use the hydrocollator, while others reported that CNAs occasionally used heat packs. The facility's policy specified that only physical therapy, occupational therapy, or charge nurses were allowed to use the hydrocollator and moist heat packs. Nursing progress notes did not document any assessment, application, monitoring, or follow-up for the heat pack application on the day of the incident, and there was no evidence of pain assessment or prn medication request prior to the injury.
Failure to Accurately Document and Report Resident Burn Incident
Penalty
Summary
The facility failed to accurately document and report an incident involving a resident who sustained a facial burn due to the application of a heat pack. The resident reported experiencing pain and visible injury, including redness, inflammation, and blistering from the left cheek to the jawline. Multiple staff interviews confirmed the presence of significant redness, blistering, and swelling, with one staff member initially suspecting shingles due to the severity of the injury. Nursing progress notes and the resident's electronic medical record documented the use of topical aloe vera and an order for oral antibiotics, as well as ongoing pain and swelling. Despite these findings, the facility's report to the State Survey Agency minimized the extent of the injury, describing it as a red area with no need for medical treatment and only a couple of small blisters. The facility's investigative findings submitted to the agency also understated the injury, failing to accurately reflect the documented clinical observations and the need for treatment. This discrepancy between the actual condition and the reported information constitutes a failure to provide accurate documentation of the event and the facility's investigative findings, as required by facility policy.
Failure to Report and Investigate Allegations of Neglect
Penalty
Summary
The facility failed to report allegations of neglect involving two residents to the administrator and State Survey Agency within the required timelines. Staff member B witnessed staff member H pushing a resident down the hall and leaving him unattended in his room without a call light, leading to the resident yelling for help. Staff member G, who was working with staff member H, confirmed the incident and reported it to staff member I, expecting an investigation. However, no action was taken, and the incident was not reported to the proper authorities. Additionally, staff member J reported finding another resident in a heavily saturated brief with a dried bowel movement, indicating neglect during staff member H's shift. This incident was also reported to the nurse on duty but was not escalated further. The facility's policy on abuse prevention and reporting requires all allegations of neglect to be investigated and reported to the proper authorities. However, staff members A and K indicated that complaints about staff member H were referred back to staff member I, who failed to act due to a personal friendship with staff member H. Staff member A was unaware of the incidents until the survey identified them and noted that staff member I did not maintain any documentation related to the incidents. The facility's failure to report and investigate these allegations of neglect resulted in a deficiency being cited during the survey.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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